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Sales Report Or Renewal Application KSC-1 - Kansas
| Sales Report Or Renewal Application Form. This is a Kansas form and can be used in Office Of The Kansas Securities Commissioner Blue Sky Secretary Of State . |
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OFFICE OF THE KANSAS SECURITIES COMMISSIONER Form KSC-1 SALES REPORT or RENEWAL APPLICATION Please indicate the purpose of filing this form by check-mark or "X" below: To report the amount of securities sold in Kansas during the registration period as required by K.S.A. 17-12a305(i) and K.A.R. 81-4-1(f). Please complete items 1 through 4 below and if an additional registration fee is required as explained in the NOTE to item 4, please enter the fee amount under item 6 and remit; or To extend the registration of securities for an additional year and report the amount of securities sold in Kansas during the current registration period as authorized by K.S.A. 17-12a305(h) and (i) and K.A.R. 81-4-1(d). Please complete all items below and remit the total fee determined under item 6. 1. Issuer Name and Address: KSC File No. Effective Date . . 2. Correspondent Name, Address and Phone No.: 3. Description of Securities: 4. Amount of securities sold in Kansas during one-year registration period $ . Amount of securities registered in Kansas $ . Amount sold in excess of amount registered in Kansas $ . NOTE: If the amount of securities sold in Kansas during the previous registration period exceeds the amount registered in Kansas as reported above, then an additional registration fee at 0.05% of the excess amount sold in Kansas may be required up to the maximum annual fee of $1,500 specified by K.A.R. 81-4-1(a) (the total of original and additional registration fees is limited to $1,500). 5. Aggregate offering price of securities to be offered in Kansas during extended year of registration: Aggregate No. of Offering Price Offering Price Shares/Units Per Share/Unit 6. Registration fee at 0.05% of the aggregate offering price above (up to $1,500): Additional fee if required for previous registration (see NOTE under 4 above): Total registration fees filed with this application $ $ $ . . . (Minimum fee = $100 and Maximum fee = $1,500 per year of registration) 7. A CURRENT PROSPECTUS WITH CURRENT FINANCIAL STATEMENTS IS REQUIRED WITH THIS RENEWAL APPLICATION, unless filed with a recent amendment (explain if not filed). ___________________________ Representative of Issuer (July-09) _______________________________ Signature ___/___/____ Date American LegalNet, Inc. www.FormsWorkFlow.com
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